Compliance and documentation
10 insurer requirements commonly missing from notes
Based on our conversations with insurers, here are 10 of the items most commonly missing from charting documentation, including examples of what it takes to meet the requirements for each.
This document is intended for educational purposes only. Examples are for purposes of illustration only. It is designed to facilitate compliance with payer requirements and applicable law, but please note that the applicable laws and requirements vary from payer to payer and state to state. Please check with your legal counsel or state licensing board for specific requirements.
1. A specific and relevant statement of progress
You should make sure your note contains a statement of progress that names specific goals and objectives, and includes a reference to the client’s treatment plan.
✅ Good example: Tom made progress toward his treatment plan goal of managing social anxiety, as shown by two successful public outings where he practiced his new mindfulness and breathing techniques.
✅ Good example: Scott's treatment plan goal is to learn three new coping skills for anxiety that work in his social life/environments. Progress today: regressing. Needs new interventions.
❌ Bad example: Tom is making progress toward his goals.
2. The location of service — even for telehealth
Your location of service should include whether the session was conducted in person or via telehealth, and an indication that telehealth sessions were performed using a HIPAA-compliant audio/visual platform
Headway’s clinical templates will automatically place the necessary statements in your final note once you select your session’s location.
❌ Bad example: [The note includes no mention of the location of the service.]
❌ Bad example: [The session details say in-person, but the notes suggest the meeting was virtual.]
✅ Good example: I had a telehealth session with Jane where I was in my private office and Jane was calling in by herself from her bedroom. We used HIPAA-compliant audio/visual software [Zoom, doxy.me, SimplePractice, etc.].
3. A complete mental status exam
Your progress note’s mental status exam should reflect at least 3 categories of the full mental status exam — such as affect, appearance, behavior, mood, orientation, speech, thought content, or thought process.
❌ Bad example: Aurora's mental status appeared stable.
✅ Good example: Aurora's affect was sad and her speech was flattened, but her thought process showed concrete reasoning and her memory was sound.
4. A description of symptoms that support the diagnosis
A detailed account of symptoms provides a more thorough reflection of the client’s mental health.
❌ Bad example: Oscar has Generalized Anxiety Disorder.
✅ Good example: Oscar's diagnosis of Generalized Anxiety Disorder is supported by the following symptoms: Oscar reports feeling irritable, and constantly finding feelings of worry difficult to control...
5. Person-centered details, like client quotes and specific behavior
Infusing specificity into your notes — such as the use of quotations from your client — helps insurers verify that the session was unique and veritable, and that you didn’t simply copy and paste from a previous session.
❌ Bad example: Sarah came into the session. She was sad.
✅ Good example: Sarah said, "I feel stressed and sad when I wake up." She pointed out that her outfit was 3 days old and her hair was disheveled.
6. A recommendation for follow-up care and the associated level of service (for psychiatric diagnostic evaluations using billing code 90791)
If you’re billing intake assessments with the 90791 CPT code, you should ensure that your notes include a recommendation for follow-up care based on your diagnosis, and the associated level of service you intend to provide moving forward.
❌ Bad example: [The documentation provides no details on future sessions or what the level of care should be going forward.]
✅ Good example: Having diagnosed Antoine with Major Depressive Disorder, I have recommended he continue to see me every 2 weeks to assess progress on goals and interventions. We plan to discuss a possible referral for medication intervention.
7. A problem statement that includes a diagnosis
The best notes reflect the “golden thread” of therapy: A consistent narrative that ties together the client’s therapeutic journey.
It begins with an initial assessment that identifies the client’s history, presenting problem, and corresponding diagnosis. These insights then flow into the goals and intervention captured in the treatment plan. And finally, your progress notes demonstrate how ongoing treatment is making progress on the goals.
Include a problem statement that reflects the client’s diagnosis to give your session notes valuable context.
❌ Bad example: [The documentation jumps straight into details of the session without any context on the initial problem or official diagnosis.]
✅ Good example: Alyssa originally sought out therapy following frequent panic attacks — at work and often in public. After diagnosing her Social Anxiety Disorder, we have been considering some interventions to help her manage public settings.
8. A risk assessment
Every session should include a risk assessment, even if the resulting documentation is that the patient denies all areas of risk. If a risk is identified, your notes should include a corresponding safety plan.
Headway's clinical templates are designed to walk you through a risk assessment.
❌ Bad example: [The client brought up a risk, but there is no risk assessment.]
❌ Bad example: [There is a risk assessment, but no corresponding safety plan.]
✅ Good example: Tom has acknowledged a temptation to engage in self-harm. As a result, we have worked together on a safety plan to avoid further harmful action, with the following steps:...
✅ Good example: Patient denies all areas of risk. No contrary clinical indications present.
9. A provider signature and credentials
Your signature and credentials lend credibility to your notes, and help to verify the legitimacy of the information within.
Headway’s clinical templates include an attestation checkbox that serves as an electronic signature. Providers may also add “/s/” next to their name to signify an electronic signature.
❌ Bad example: [Note has no signature, or doesn't include the provider's credentials.]
✅ Good example: Note signed by provider /s/ Jane Doe, Licensed Marriage and Family Therapist
10. Session start and stop times that reflect the CPT code’s requirements
If you’re billing with one of those codes, your notes should include a start and stop time for the session that is within an acceptable margin of that code’s session length. For example, a 90837 session should have start and stop times no closer than 53 minutes apart.
The actual time billed should reflect the time spent in face-to-face contact with the patient.
❌ Bad example: [Session start and stop times are 35 minutes apart, but provider bills CPT code 90837 (only for sessions 53+ minutes).]
✅ Good example: [Session length was 63 minutes, and provider billed CPT code 90837.]